Hello! We want to meet the behavioral health needs of your child as thoroughly and as successfully as possible. The more prepared we all are for your visit, the more we can accomplish. Please fill out the attached forms at home and return them to the office. If a page seems like it does not apply to your child, you may skip it. If you have questions when filling out the forms, feel free to call our office. After we receive the completed packet, we will reach out to you to schedule the first appointment. The physician will review the forms before your
appointment

During the first visit, we will spend time talking with both you and your child, sometimes together, and possibly separately. Initial information that is important to get from you includes your understanding and assessment of
the problem, timeline, and family history. Important information from your child is who they are and how they feel.

We know from working with kids and families, that sometimes it is easier to get information from parents/guardians when they are alone, and not having to focus on their child. We also know that sometimes children open up to us more when their parents aren’t listening. For this reason, we may spend some time during visits with either a parent or child alone. We can be flexible in how we divide our time, however, insurance requires that the child be present for at least part of the visit every time. We will wrap up each visit with a quick discussion of the plan going forward, and let you know when you should schedule a follow-up visit. When scheduling a visit, please make sure both you and your child are available at the time of the visit. For most families, the first follow-up is about 1 month later, but if you feel you need more time to talk, we can always schedule a visit sooner. Regular follow-up appointments are crucial in situations like these, so we can help your child and family be successful at making changes and improving your life at home.

PLEASE NOTE:
Children under the age of 12 cannot be left unsupervised at our clinic. Please arrange for another responsible adult to come with you to the visit, so that we can have the opportunity to speak with you alone. If this is a barrier for you, please let us know so we can accommodate your family.

We look forward to working with you and your child!

Thank you,

Rogue Community Health Pediatrics

Instructions: Please rate each behavior from 0 (absent) to 9 (serious). Circle only one number beside each item. A zero means that you have not seen the behavior in this child during the past week, and a 9 means that you have noticed it to be either very serious or to occur very frequently.

Directions: Each rating should be considered in the context of what is appropriate for the age of your child. When completing this form, please think about your child’s behaviors in the past 6 months.